Antimicrobial Resistance in Nepal

Antimicrobial resistance (AMR) is a global problem to animal and public health. It has drawn the attention of public health experts, stakeholders, and medical science due to the substantial economic loss that it causes to individuals and nation as a whole. Various cross-sectional studies and some national surveys in developing countries have shown increase in the burden of antimicrobial resistance. Nepal is one of the major contributors to the growing burden of AMR due to widespread irrational use of antibiotics along with poor health care systems poor infection control and prevention measures. This review was conducted to summarize the situation of AMR in Nepal, determinants of AMR, current government intervention strategies and the way forward to reduce the AMR burden in Nepal. Available cross sectional reports warn that bacterial pathogens are becoming highly resistant to most first- and some second-line antibiotics. The irrational and injudicious use of high doses of antibiotics for therapy and sub-optimal doses as growth promoters are leading causes of AMR in Nepal. Establishment of a surveillance programme and a national plan for containment of AMR, following the National Antibiotics Treatment Guideline 2014 and generation of awareness among veterinarians, technicians, and medical physicians on prudent use of antimicrobial drugs in Nepal could reduce the burden of AMR. In addition, there is a need to develop a national laboratory strategic plan to provide guidance and governance to national laboratories.

Pneumococcal vaccines

Streptococcus pneumoniae continues to take a heavy toll on childhood mortality and morbidity across the developing world. An estimated 10.6 million invasive pneumococcal diseases (IPDs) occur every year, with nearly 1 million deaths in children under 5 years of age. Introduction of vaccines in the childhood immunisation programme in developed world has brought down the incidence of the disease considerably. However, childhood immunocompromising illnesses including HIV have increased the risk of IPD several folds. There is also a growing concern on the increasing antibiotic resistance among these invasive strains to penicillin, other beta-lactams and macrolides, making treatment difficult and expensive. It is estimated that about 62% of IPD worldwide is caused by the 10 most common serotypes. Although the ranking of individual pneumococcal serotypes causing serious disease varies among nations, the 7-13 serotypes included in pneumococcal conjugate vaccines (PCVs) may prevent 50%-80% of all paediatric pneumococcal diseases globally. The World Health Organization has recommended the use of PCV-10/13 in the national immunisation programmes (NIPs) of developing countries. Four doses of PCV-13 have been recommended by the US Association of Pediatrics and Centers for Disease Control and Prevention, at intervals of each 2 months for the first 6 months and by the 12^th to 15^th months after birth. This is expected to reduce the morbidity and mortality associated with IPD and simultaneously decrease colonisation with circulating antibiotic-resistant strains in immunized communities. Nevertheless, continued surveillance of antimicrobial resistance in non-vaccine serotypes is necessary to prevent the resurgence of resistance. Other virulence factors which are not serotype specific also need to be studied to overcome the drawbacks of serotype-specific pneumococcal vaccines. PCV-13 was launched during May 2017 under the NIP of five Indian states with the highest pneumococcal diseases in the country and is expected to be rolled out in the other parts of the country in the coming days.

Serotypes & penicillin susceptibility of Streptococcus pneumoniae isolated from children admitted to a tertiary teaching hospital in Malaysia

Background & objectives:

Streptococcus pneumoniae (pneumococcus) is a highly invasive extracellular pathogen that causes diseases such as pneumonia, otitis media and meningitis. This study was undertaken to determine the serotype diversity and penicillin susceptibility of S. pneumoniae isolated from paediatric patients in a tertiary teaching hospital in Malaysia.

Methods:

A total of 125 clinical isolates collected from January 2013 to May 2015 were serotyped using seven sequential multiplex polymerase chain reactions. The susceptibility of these isolates to penicillin was also investigated.

Results:

Serotypes detected among the isolates were serotypes 3, 6A/B, 6C, 11/A/D/F, 15A/F, 19A, 19F, 23A, 23F, 34. Serotypes 19F and 6A/B were the most prevalent serotypes detected. Most of the S. pneumoniae were isolated from nasopharyngeal samples of children below five years of age. Majority of the isolates were penicillin susceptible. Only 5.6 per cent of the isolates were non-susceptible to penicillin, mostly of serotype 19F.

Interpretation & conclusions:

Our study revealed the distribution of various serotypes in S. pneumoniae isolates obtained from children in a teaching hospital at Kuala Lumpur, Malaysia and decreasing rates of penicillin resistance among them. The shifts in serotypes and susceptibility to penicillin from time to time have been observed. Continuous monitoring and surveillance are pivotal for better infection control and management of pneumococcal infections among children.

Incidence and aetiology of bacterial meningitis among children aged 1-59 months in South Asia: systematic review and meta-analysis

BACKGROUND

Bacterial meningitis is a significant cause of morbidity and mortality worldwide among children aged 1-59 months. We aimed to describe its burden in South Asia, focusing on vaccine-preventable aetiologies.

METHODS

We searched five databases for studies published from January 1, 1990, to April 25, 2017. We estimated incidence and aetiology-specific proportions using random-effects meta-analysis. In secondary analyses, we described vaccine impact and pneumococcal meningitis serotypes.

RESULTS

We included 48 articles cumulatively reporting 20,707 cases from 1987 to 2013. Mean annual incidence was 105 (95% confidence interval [CI], 53-173) cases per 100,000 children. On average, Haemophilus influenzae type b (Hib) accounted for 13% (95% CI, 8-19%) of cases, pneumococcus for 10% (95% CI, 6-15%), and meningococcus for 1% (95% CI, 0-2%). These meta-analyses had substantial between-study heterogeneity (I² > 78%, P < 0.0001). Among studies reporting only confirmed cases, these three bacteria caused a median of 78% cases (IQR, 50-87%). Hib meningitis incidence declined by 72-83% at sentinel hospitals in Pakistan and Bangladesh, respectively, within two years of implementing nationwide vaccination. On average, PCV10 covered 49% (95% CI, 39-58%), PCV13 covered 51% (95% CI, 40-61%), and PPSV23 covered 74% (95% CI, 67-80%) of pneumococcal meningitis serotypes. Lower PCV10 and PCV13 serotype coverage in Bangladesh was associated with higher prevalence of serotype 2, compared to India and Pakistan.

CONCLUSIONS

South Asia has relatively high incidence of bacterial meningitis among children aged 1-59 months, with vaccine-preventable bacteria causing a substantial proportion. These estimates are likely underestimates due to multiple epidemiological and microbiological factors. Further research on vaccine impact and distribution of pneumococcal serotypes will inform vaccine policymaking and implementation.

Microbial Infections and Antimicrobial Resistance in Nepal: Current Trends and Recommendations

Antimicrobial resistance is a life threatening challenges to the world. Most of the well-known antibiotics are currently ineffective to several microbial diseases. Ampicillin, metronidazole, amoxicillin, cotrimoxazole, chloramphenicol, ciprofloxacin, nalidixic acid, gentamicin, and ceftazidime are common antibiotics whose resistance pattern has been elevated in recent years. The rise and dissemination of resistant bacteria has contributed in increasing cases of antimicrobial resistance. Multi-drug Resistant (MDR) organism such as Staphylococcus aureus, Pseudomionas aeruginosa, Escherchia coli, and Mycobacterium tuberculosis are principal problems for public health and stakeholders. Globally, issues of antimicrobial resistance are major concern. In the context of Nepal, insufficient surveillance system, lack of appropriate policy, and poor publications regarding the use of antibiotics and its resistance pattern has misled to depict exact scenario of antimicrobial resistance. This mini-review presents current trends of antibiotic use and its resistance pattern in Nepal. In addition, global progression of antibiotic discovery and its resistance has been covered as well. Furthermore, use of antibiotics and possible ways on improvement of effectiveness have been discussed.

Distribution of serotypes, vaccine coverage, and antimicrobial susceptibility pattern of Streptococcus pneumoniae in children living in SAARC countries: a systematic review

INTRODUCTION

Each SAARC nation falls in the zone of high incidence of pneumococcal disease but there is a paucity of literature estimating the burden of pneumococcal disease in this region.

OBJECTIVE

To identify the prevalent serotypes causing invasive pneumococcal disease in children of SAARC countries, to determine the coverage of these serotypes by the available vaccines, and to determine the antibiotic resistance pattern of Streptococcus pneumoniae.

METHODS

We searched major electronic databases using a comprehensive search strategy, and additionally searched the bibliography of the included studies and retrieved articles till July 2014. Both community and hospital based observational studies which included children aged ≤12 years as/or part of the studied population in SAARC countries were included.

RESULTS

A total of 17 studies were included in the final analysis. The period of surveillance varied from 12-96 months (median, 24 months). The most common serotypes country-wise were as follows: serotype 1 in Nepal; serotype 14 in Bangladesh and India; serotype 19F in Sri Lanka and Pakistan. PCV-10 was found to be suitable for countries like India, Nepal, Bangladesh, and Sri Lanka, whereas PCV-13 may be more suitable for Pakistan. An increasing trend of non-susceptibility to antibiotics was noted for co-trimoxazole, erythromycin and chloramphenicol, whereas an increasing trend of susceptibility was noted for penicillin.

CONCLUSION

Due to paucity of recent data in majority of the SAARC countries, urgent large size prospective studies are needed to formulate recommendations for specific pneumococcal vaccine introduction and usage of antimicrobial agents in these regions.

Burden of invasive pneumococcal disease in children aged 1 month to 12 years living in South Asia: a systematic review

Objective

The primary objective was to estimate the burden of invasive pneumococcal disease (IPD) in children aged 1 month to 12 years in South Asian countries.

Methods

We searched three electronic databases (PubMed, Embase and the Cochrane Library) using a comprehensive search strategy, we manually searched published databases (Index Medicus and Current Contents) and we also searched the bibliographies of the included studies and retrieved reviews. The searches were current through June 2013. Eligible studies (community-based and hospital-based) were pooled and a separate analysis for India was also completed. A meta-regression analysis and heterogeneity analysis were performed. The protocol was registered with PROSPERO registration number CRD42013004483.

Results

A total of 22 studies surveying 36,714 children were included in the systematic review. Hospital-based prospective studies from South Asia showed that 3.57% of children had IPD, and 15% of all bacterial pneumonia cases were due to Streptococcus pneumoniae. Indian studies showed that the incidence of IPD was 10.58% in children admitted to hospitals with suspected invasive bacterial diseases, and 24% of all bacterial pneumonia cases were due to S. pneumonia. Population-based studies from South Asian countries showed that 12.8% of confirmed invasive bacterial diseases were caused by S. pneumonia whereas retrospective hospital-based studies showed that 28% of invasive bacterial diseases were due to S. pneumoniae. Meta-regression showed that there was a significant influence of the antigen testing method for diagnosing IPD on IPD prevalence.

Conclusion

S. pneumoniae is responsible for a substantial bacterial disease burden in children of South Asian countries including India despite the presence of high heterogeneity in this meta-analysis. Treatment guidelines must be formulated, and preventive measures like vaccines must also be considered.

Antimicrobial susceptibility patterns of Streptococcus pneumoniae over 6 years at Gondar University Hospital, Northwest Ethiopia

OBJECTIVE

To assess the magnitude and antimicrobial susceptibility patterns of Streptococcus pneumoniae isolates from various clinical specimens.

METHODS

A record based on retrospective study was conducted at Gondar University Teaching Hospital from September 2007 to January 2012. All patients who visited Gondar University Hospital and provided clinical specimens (body fluids, discharge, swab and blood) for routine bacteriological culturing and antimicrobial susceptibility testing were taken for analysis. Clinical specimens were processed for bacterial culture according to the standard procedures. Antimicrobial susceptibility test for isolated organisms was done using agar disk diffusion method. The data were entered and analyzed using SPSS software version 16 package.

RESULTS

One hundred and fifty three Streptococcus pneumoniae were isolated from patients who visited Gondar University Teaching Hospital bacteriology laboratory for culture. Majority of the pneumococcal isolates were from inpatients [111(72.5%)], and 74(48.4%) were from body fluids. Out of the total isolates, 93(61%) were found to be resistant to at least one antibiotic used for susceptibility testing. Forty eight (43.2%) of the isolates were multi-drug resistant (resistant to two or more drugs). The resistance rate noted for both ciprofloxacin 17(11.1%) and ceftriaxone 15(9.8%) were alarming.

CONCLUSIONS

High proportions of the isolates tend to be increasingly resistant to the commonly prescribed drugs. The recommended drug of choice like ciprofloxacin and ceftriaxone were found to be less susceptible in the study area. Based on the findings, we therefore recommend that antimicrobial agents should be inspected for acceptable activity before they are prescribed and administered empirically. Further study with a better design and survey of antimicrobial susceptibility at large scale shoule be performed to draw advanced information.

Serotype distribution and antibiotics susceptibility pattern of Streptococcus pneumonia in Iran

Background

The development of antibiotic resistance among Streptococcus pneumoniae strains has caused significant health problems worldwide.

Objectives

The aim of this study was to determine antibiotic resistance pattern and serotypes distribution of Streptococcus pneumoniae strains isolated from clinical specimens.

Material and Methods

A total of fifty Streptococcus pneumoniae strains were isolated from Tehran Hospital’s laboratory from 2008 to 2012. Antimicrobial susceptibility testing was performed using broth microdilution method and minimum inhibitory concentration (MIC) of each strain was determined. to verify the resistant strains and demonstrate the presence of antibiotic resistant genes, the PCR was performed.

Results

The study showed that three strains (6%) and six strains (12%) indicated intermediate resistance and complete resistance to penicillin, respectively, 58% strains were susceptible to ceftazidime, two ones (4%) indicated resistance to ciprofloxacin, one (2%) indicated intermediate resistance to ceftriaxone , two strains (4%) indicated complete resistance and four (8%) strains indicated resistance to vancomycin.

Conclusions

The emergence of Streptococcus pneumoniae strains with multiple resistance needs permanent monitoring of antibiotic susceptibility patterns of clinical isolates. We have found that ceftazidime is not a suitable drug for choosing the treatment of pneumococcal infections.